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We report a unique case of orthotopic domino livertransplantation for a patient with ALF: a noncirrhoticliver graft with HCC was used as bridge therapy untila permanent deceased donor graft became available.A 42-year-old Hispanic woman presenting with ALFwas admitted to the emergency department and waspromptly listed for emergency liver transplantation.However, her clinical deterioration progressed rapidly,the patient required mechanical ventilatory support,and an epidural intracranial pressure monitor wasplaced. The patient developed intracranial hyperten-sion (25-30 mm Hg), which was successfully con-trolled with medical therapy. Synchronously,scheduled living donor liver transplantation (LDLT)was being performed for a 60-year-old female patientwith a history of recurrent HCC in a noncirrhotic liver.This patient had previously undergone a series of sur-gical and ablative treatments. The actual tumor bur-den was 2 HCC lesions (each 20 mm in diameter), theserum alpha-fetoprotein level was 2.4 ng/mL, and novascular or extrahepatic metastasis was found at thetime of LDLT.Progressive worsening of an already critical clinicalcondition in the first patient, the absence of either adeceased donor or a living donor after 5 days on thewaiting list, and no access to liver support systems orbioartificial devices at that time led the transplantteam to consider a domino liver transplant using theexplanted noncirrhotic liver with HCC from the secondpatient undergoing synchronous LDLT as bridge ther-apy. Consent was obtained from both the recipientand donor families, the institutional ethics committee,and the Instituto Nacional Central Unico Coordinadorde Ablacion e Implante. A sequential triple-procedureschedule was followed: left lobe LDLT; back-tableresection of the two 2-cm HCC lesions in segments VIand IV; and, finally, domino implantation of the HCCliver graft with the piggyback technique. The coldischemia time lasted 4 hours, and the warm ischemiatime was 40 minutes. Shortly after transplantation,vasopressor infusion was discontinued, and the intra-cranial pressure parameters improved to 15 to 17 mmHg (Fig. 1). Twelve hours after the domino procedure,a deceased donor graft from a 49-year-old female,located 600 km from the hospital, was made availablefor this patient. The deceased donor liver transplanta-tion procedure began 11 hours after the completion ofthe bridge domino liver transplant with the resectedHCC graft, and it lasted a total of 165 minutes with acold ischemia time of 6 hours.A pathological examination of the explanted dominoHCC liver graft confirmed 2 small HCC nodules: one